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Improving hand offs between police and emergency departments

Police have been described as “street corner psychiatrists.” They are often the community resource that responds at all hours when emergency calls come in for someone in mental health crisis. Police also serve a gatekeeper function in determining what services are required for an individual in crisis.

They are tasked with the important and difficult decision of whether the person experiencing a mental health crisis is directed to the mental health system, or whether they ought to enter the criminal justice system.

Once the decision has been made that the person requires a medical assessment, police services escort and accompany the individual to the emergency department until the transfer to the appropriate health care provider is complete.

Waiting for the person to be assessed can involve lengthy wait times for police, which means that they aren’t able to respond to other calls in the community.

Jodi Younger, clinical director of Psychiatry and Addiction Services at St. Joseph’s Healthcare Hamilton also highlights that having an officer accompany a patient in the emergency department can reinforce stigma and criminalization of the mentally ill. She notes that “the vast majority of people brought in by police in mental health crisis are low risk [of violence] and no different than a patient brought in by a family member or friend.”

Over the past decade, there have been increased efforts nationally to improve the transfer between police and the health care system. However, these efforts are often fragmented. Given this fragmentation, and the different organizations and sectors involved, there are challenges in measuring the extent of police time spent dealing with mental health crises, and the success of these collaborations.

Police apprehensions for mental health

The police decision to apprehend someone experiencing a mental health crisis and order them to undergo a medical assessment involves different legislation in each Canadian province and territory. This is different from the police bringing in someone who has committed a crime for medical clearance, before the person is charged through the criminal justice system.

For example, section 17 of the Ontario Mental Health Act allows police officers to apprehend individuals who are acting in a way that the officer believes may be of harm to themselves or others, or show an inability to care for themselves.

Once an apprehension is made under the Mental Health Act, police are under a legal obligation to transport that person to be examined by a physician. After examination, there are a number of options – including releasing the person back into the community or admitting them to the hospital on a voluntary or involuntary basis for further assessment and care.

Improving the transfer between police & emergency departments

Hospital emergency departments are required to treat all patients according to their level of need.

Many Canadian emergency departments are busy and have long wait times. Patients with less urgent needs often wait for considerable periods of time before being seen by a physician.

CTAS 1 is the highest level of need for those patients who are severely injured or acutely ill and should be seen immediately. These patients include those who have suffered a cardiac arrest or major trauma. CTAS 5, the lowest level of need, includes patients who have non-urgent medical complaints, but nevertheless require medical care such as stitches or care for a sore throat.

A 2012 study of individuals presenting to Ontario emergency departments with mental illness complaints found that most were scored at a CTAS 3 . While these individuals wait to be seen in the emergency department, so too do the police.

An example of one such collaboration is between the Ottawa Police Services and The Ottawa Hospital, which since 2009 has a protocol in place to reduce police wait times.

Donna MacNeil-Charbot, Liaison officer for the Ottawa Police Services with Ottawa-area hospitals said the collaboration was motivated by concerns that “if we’re waiting with a patient at the hospital, we’re not able to serve the community as police officers”.

The collaboration was established after a review of relevant legislation and safety requirements for both the hospital and police. A process was put in place whereby individuals in mental health crisis accompanied by police were flagged as a priority to be seen by emergency department staff. Dr. Guy Hebert, Chief of the Emergency Department at the Civic campus of The Ottawa Hospital, says that they are “prioritized within reason” within the group of patients at their triage level.

Following medical assessment, a decision is made about whether it is safe for the patient, as well as hospital staff, for the police officer to leave the emergency department Then, hospital security takes over monitoring the patient in the emergency department.

Ottawa Police Services are unable to provide data to Healthy Debate on the wait times prior to, and following the collaboration being put in place. However, MacNeil-Charbot says that anecdotally there has been a marked reduction in wait times for police. She highlights that this collaboration has built important good will between the hospital and police in recognizing their shared responsibility to provide services to those in mental health crisis.

Another collaboration highlighted in the 2013 report is between Hamilton Police Services and St. Joseph’s Healthcare Hamilton. This included developing a protocol and form to assess patients’ level of risk jointly between police and hospital staff. If a patient was assessed at medium or low risk, the officer could leave. Since the collaboration began 18 months ago, it has reduced average police wait times in the St. Joseph’s Healthcare emergency department from 125 minutes to 80 minutes. This information is specific to one hospital’s’ emergency department and one police force.

More information is needed

There are many similar collaborations happening across Canada, and while there are some data for specific organizations, there is a lack of information available on their broader impact.

This is in part due to challenges in identifying the scope of problem in the first place – there is no provincial or national information on the number of apprehensions by police under mental health legislation, or on the percentage of police calls that are related to mental health issues.

When information is collected, it is done so by individual police forces. A Canadian Medical Association Journal article noted that in 2011 Toronto Police apprehended 8500 people under the Ontario Mental Health Act. Jim Chu, Chief Constable of the Vancouver Police Service is quoted as saying that apprehensions under the BC Mental Health Act have quadrupled since 2002, which would mean a quadrupling of police bringing patients to the emergency department for these calls.

And, apprehensions are just one aspect of the role police play in responding to people in mental health crisis.

Terry Coleman, retired Moose Jaw Chief of Police and adjunct professor at the University of Regina, says that while “police services have good measurement systems to facilitate collecting how many times they’ve written a ticket or made an arrest, there is far less information available on police interactions with those who have mental illness.”

Experts and advocates suggest that there is an increase in the number of calls to the police when individuals are experiencing a mental health crisis. Some experts have pointed to de-institutionalization, that is the closure of many inpatient psychiatric facilities and beds, as fueling this increase. However, others, like Coleman, note that there has also been a significant growth in the awareness and education of police officers to help them recognize and deal with individuals in mental health crisis.

Promising collaborations, and future challenges

The sense that more police resources are needed to deal with mental illness has led to other formal partnerships between health care system providers and law enforcement.

For example, Alberta Health Services funds a Police and Crisis Team (PACT) which is a mobile crisis team that brings together mental health professionals and police. The team responds to calls when someone is in mental health crisis and in some cases offers an alternative to the emergency department or criminal justice system, by having mental health providers who can connect individuals in crisis with community-based health care resources.

Laurie Beverley, Provincial Executive Director of Addiction and Mental Health for Alberta Health Services states that while “we cannot cite statistics in terms of the impact of programs such as PACT on emergency departments, it stands to reason that if the services are being provided, and linkages are being made with mental health, addiction, social and support services in the community, then there will be a reduction in the use of emergency departments.”

Beverley’s perspective is echoed by many voices within policing. In August 2013, the Canadian Association of Chiefs of Police issued a press release highlighting a growing burden on police in their first response capacity for those in mental health crisis.

It states “police should not be the front line on mental health issues. Lack of funding in the health care system is putting these people on the streets. We need to shift from a point of crisis to preventing the crisis from occurring in the first place.”

However a research article published last week highlights major gaps in research about the effectiveness of mental health crisis intervention teams in reducing violence during confrontations between people in crisis and the police, and in diversions from emergency departments or the justice system towards mental health treatment.

MacNeil-Charbot points out that police officers are on call 24 hours a day, 7 days a week, while crisis teams and community mental health services tend to not work around the clock. “Mental health apprehension and crises happen at all hours of the day and night” she says “and we will still get calls that end up in emergency departments.”

Enter the debate: reply to an existing comment

12 comments

Timothy M. SmithFebruary 27th, 2014 at 10:51 am

I want to congratulate the authors for their extensive research in outlining this very difficult issue. The Canadian Association of Chiefs of Police have partnered with the Mental Health Commission of Canada to discuss these exact issues. The March conference is entitled: “Balancing Individual Safety, Community Safety and Quality of Life – A conference to improve interactions with persons with mental illness” A brief promotional video can be found at: http://www.cacp.ca/media/Videos/PMI_EnglishSML.mp4 Please feel free to follow the conversation on twitter #MHpolice

As society has de-institutionalized the care of the mentally ill to a variety of community based provider organizations (perhaps under-resourced) it would seem sensible and appropriate that the response to any individual crisis include such providers with or without police as indicated by the circumstances.

Intriguing article on a thorny situation that I know all to well as an ED physician. I think we need to address the tendency in the culture of medicine to denigrate patients who arrive in police custody – just as we must resist the urge to “side” with law enforcement officials. It’s difficult to do when you’re working in a busy ED.

When police transport patients to hospital under the Mental Health Act, they are best thought of as performing as a “Mental Health Ambulance”. Like paramedics, they want/ need to get back on the road, and ED’s should not delay them. We would not expect a paramedic crew to wait for the emergency physician to assess their patient, why should police? The paramedics give verbal report to the nursing staff, leave a written record, and move on. The only difference with police is that, given the nature of these cases, hospital security needs to be called in case the patient tries to leave before the assessment is completed.
Usually the police stay for the assessment under the mistaken belief that a physician’s determination of the need for involuntary certification (“Form 1” in Ontario) is required before security can assume patient observation and allow them to depart. This is a common myth among hospital staff, security contractors, and even police. It is a dangerous myth because tragedies have occurred in the interval between patient arrival and MD assessment that could be prevented by authorizing a nurse to request security to watch a patient. The authority for a nurse, or security officer, to act in this manner is found in common law rather than legislation but is well documented and accepted by many facilities. The Ontario Hospital Association has a legal opinion to this effect on it’s website; see question 2 and answer athttp://www.oha.com/CurrentIssues/LegislativeAnalysis/Documents/Mental%20Health%20and%20the%20Law%20-%20Frequently%20Asked%20Questions.pdf
In Toronto Central LHIN we have developed a model template for transfer of care in these situations that calls for our hospitals to involve security on the patient’s arrival, and allow the police to leave once the nurse has received verbal report and the police have completed and left with us their documentation. All of our hospitals have accepted the approach in principle; several had their legal teams review it. Toronto Police Services has also accepted the approach. This approach has been effect in my own hospital for many years without incident. Transfer of care times using this approach should routinely be half an hour or less.
Many ED’s in Canada submit data to CIHI through “NACRS” – the National Ambulatory Care Reporting System. In Ontario submission is mandatory. NACRS identifies patients brought to the ED by police but did not distinguish between mental health patients left for assessment from patients under arrest brought for medical clearance and then taken to custody. In order to help with identification and analysis of the important mental health population brought to ED’s by police, CIHI created the ability to separate these two populations by use of a special project field, called “Project 270”. Use of this field has been mandatory in Ontario since April 1, 2013. I hope we will also one day collect transfer of care times for this population also, just as we do for ambulance arrivals. Good data is crucial to process improvement and accountability in our system.

Written MHA incident reports vs. verbal reports are an huge issue for us. Would you hand over cash for a used car with a only a verbal agreement? A car is trash compared to what we are talking about, human beings. We believe most police and medical staff to be ethical. But, there are those who “Act in Bad Faith”. How could any capable citizen (not at risk to themselves or others) even begin to defend themselves against an unlawful arrest without being allowed a call to lawyer or family. When police leave and only a verbal subjective incident report to medical staff is left then there is no way for medical staff to ask police about contradicting information from the detainee? The officers will be off carrying on with their duties, and the capable citizen may be refused a call to lawyer and or family if they refuse to speak with a psychiatrist. If medical staff deny the detainee their Charter Rights Section 10 call to lawyer to check validity of detention to ensure it’s not unlawful, then medical staff may order the detainee out of their clothes and drug them.
Our solution is video of police interaction with person in question, as well as video of detainee walking into ER beside police. I think if these provisions are in place, the police may ask more questions before they easily haul someone against their will to ER for a mental health assessment.

#1 – I cannot tell you the amount of times and sheer volume of people (nurses and paramedics) seen personally just casually lounging in triage with patients …

further more – your point about form 1 and hospital security is pure garbage..
patient watches on NON-formed patients is often one of the most volatile tasks included in my occupation. occasionally the police drop someone off who is pretty much passed out.. in some cases they wake up, assuming they have been arresting and decided they want to fight the “prison guard” – who is infact a minimally trained minimum wage security guard… high turnover results in a lack of experience.. when you know the floor cleaner is making 22$ an hour but your only making 11 it has an impact on moral and just how much risk you are willing to put yourself in…

further more the people who are not formed will often at some point decide they want to leave.. at which point, nursing staff who is clueless in regards to securities roles and authority, nurses are looking at you to put hands on the NON FORMED Patient – which may result in civil and even criminal consequences, IN ADDITION – even regarding FORM 1 patients, you are frequently given the impression and treated as such that you are expendable and your job is on the line ALL the time.. which is actually the case…

for instance, a security guard is sucker punched by a form 1 patient – the security guard cannot hit back to defend himself unless he is under sustained blows.. that is pretty much the unwritten rule where I work, so we are in effect NOT allowed to defend ourselves or others in a legal and reasonable way, we are actually expected to take an assault as “part of the job” and any self defence other than basically grabbing and restraining is seen as too much force, you are fired, and even if proven wrongful termination your employment record is now tarnished and there goes your future career in policing

IN HOUSE security should be MANDATED, not only would it allow for site specific training, equal and reasonable pay for security staff, rather than 22$ an hour to a company which in turn gives the guard only 11$ an hour.. in house security would also allow for shared policy and coordination with nursing staff, rather than the current us vs them scenario which so often plays out when you have private security companies.

patients who are non-formed are often belligerent with nurses, who in turn deny them care for spite.. for instance, forcing the patient to soil themselves rather than assist, all the while sitting at the desk talking with other nurses about how they wont help because they are pissed.. this happens routinely and OFTEN results in a MORE hostile encounter with staff.. I can assure you that this happens..

for the last time, the model you are praising would work in the right circumstances.. but when you start researching the private security firms that are often contracted out for healthcare services, you will see the companies values are basically built as a house of cards..

As a civil liberties advocate, and one who has been railroaded into a forced involuntary mental health assessment and drugging without being allowed a call to lawyer or family, I believe many can learn from my story as to what happens when misinformation is presented to police where only a subjective verbal report is provided to medical staff from police involved. In my case months later, the ER physician wrote an addendum in the ER file regarding his ER Consult report on me; “I wrote Mr. S was brought in from Revenue Canada by police, it was actually the Law Courts” I was held and drugged for 11 days, I refused to speak with a psychiatrist because I did not trust them, because they were refusing me my requested call a lawyer family t and family to let them know where I was and what was happening. On day 11 I spoke with psychiatrist, after 10 minute conversation he said you are free to go!

We all need to look at what police do after receiving a call from a caller who may be “Acting in Bad Faith” who may be out to discredit the citizen in question or to attempt to gain control of a person or their asserts for personal gain. A Vancouver police officer told reporter Rob Wipond “we can’t afford to have that conversation”, read the story in Dec. 2013 Focus Magazine, also on-line, the story is on page 50 with my picture, link http://www.focusonline.ca/sites/default/files//Focus_2013-12_December.pdf .
Also my conversation with Janine Bancroft the University of Victoria radio program “The Winds of Change” on Feb, 27th, 2014 @ 11:30 am on podcast.

I had my own business, rented a beautiful home for our family, we had 3 daughters under the age of 6 at the time, I spent every last penny investing in my business when I was locked away for 11 days, they took the bread winner away, the horrific fall out, the failure to allow a detainee their civil liberties is something that no one could ever understand how it feels, I was calm, “looks nervous”, well who wouldn’t look nervous. Three people with identical names living in the same city, a person with a criminal record somewhere in Canada with identical name (my name was red flagged before with company I had worked with, months later letter Attorney General/police letter confirmed I was not the person in question with the criminal record) so how easy misinformation can ruin a citizen’s life. Criminals are allowed their Sec. 10 call to lawyer, they are not drugged, so lets talk about How police treat information from callers who may be “Acting in Bad Faith”. How could anyone defend themselves in such a situation without a call to lawyer? Drugging a citizen because they refuse to speak with a psychiatrist, how draconian has Canada become.

Do the powers to be actually want to hear what we have to say? The Mental Health Commission Canada and the National Chiefs of Police Association have jointly put together a conference in Toronto for next week to discuss police and mental health. My application to attend the mental health talks was turned down. People with “lived experience” could apply to get funding to attend which I did, but my application was denied.

So who gets to attend? The jailers being a combination of; (police) (medical staff) (psychiatrist)? Are they cherry picking who they want to hear from? Do they have an agenda to discuss which my views as an advocate are not welcome? I assume that all police and medical staff who want to attend this conference will have all their expenses paid for by the taxpayer one way or another. But if they are attending to hear what’s wrong with the system, then they may be out of luck if the participants who should attend can’t afford to attend.

Advocates with “lived experience” will have to find other ways of exposing the flaws and the lack of accountability within the policing and mental health system. My one simplest solution is for all police to stop providing medical staff with verbal subjective incident reports, imagine an un-ethical caller to police who is (‘Acting in Bad Faith”) fabricating a story in order to get a capable citizen who is not a risk to harm themselves or others discredited for the caller’s personal gain. Canada’s Charter of Rights and Freedoms Act will not protect such a detainee from being forced to remove their clothes, or forced to take medication and certainly it’s no guarantee to prevent them from being certified unlawfully against their will. These stories need to be told, and only by a person who has lived to tell their story.

This is a very well written and well researched article. Thanks to the Canadian Association of Chiefs of Police for sharing it on twitter into the hash tag #MHPolice which I am following closely, allowing me to find the article, and read it. I am the Toronto Police Service Corporate Communications Social Media Officer. I have worked as a police officer since 1990, 12yrs with Peel Regional Police and 12yrs with Toronto Police. I have dealt with many cases first hand of mental illness and have been that police officer waiting at the hospital with someone apprehended under the powers of the Mental Health Act far too many times. Since becoming the Toronto Police Social Media Officer in 2010, and using social media as a police officer since 2004, I have come to see an opportunity using relationships and technology to avoid people getting to a crisis situation that leads to being apprehended or a violent confrontation occurring between a person experiencing crisis and a family member, friend, co-worker, health care worker, social worker, education staff, or at worst, a violent confrontation with police. Many people I have encountered simply want to talk. They want someone to listen, and are often reaching out for someone to talk in social media, often after business hours. Now that police and social services are starting to use social media officially, many people are reaching out asking to talk. The challenge comes with not enough timely resources being available for the person experiencing crisis to speak with. A further challenge comes with the fact that social media is by nature very public. I post this comment here because I have had the opportunity to work alongside a street nurse named Anne Marie Batten here in Toronto in a collaborative way with many people in social media who are in crisis, and making a very public call for help for crisis situations like suicide. A nurse reaching out on twitter, facebook, tumblr, an online chat forum saying ” I’m a nurse, can I help?” has proven very effective at helping the person de-escalate from crisis, and often avoid the need for police or emergency hospitalization. This has also avoided the need to do exigent circumstances traces of social media posts, which for law enforcement is a time consuming and often frustrating experience. This nurse, Anne Marie, sees huge potential, and has started up a not for profit corporation that is in its infancy called “Real Time Crisis Intervention” I personally think that this collaboration in social media transfers into success in a timely manner for people who otherwise find themselves in a crisis situation. The benefits are huge for the people who are served, and for the community at large, including the issue of police and hospital emergency room resources. The challenge appears to be that stakeholders don’t understand how this works…how simple it really is to do, and how effective it could be if implemented on a large scale basis. Please seek out Nurse Anne Marie Batten for more info. She is working night and day for all the right reasons to make “Real Time Crisis” a reality. To contact Anne Marie e-mail: RealTimeCrisis@gmail.com or tweet her @AnneMarieBatten

Being a police officer or a medical practitioner doesn’t come with a FREE “Keep out of the Psych Ward card”. Both professions can be very demanding and stressful at times. But what happens when a police officer or medical professional is having an off day, it could be related to mental illness, it could be the first time they snap, maybe colleagues haven’t detected their illness yet, maybe the professional was able to mask their illness by flying under the radar, but I ask this, who is going to protect the citizen detained under a provincial Mental Health Act by the professional in a questionable state?

Misinformation; What if police are relying on fabricated/misinformation from a caller “Acting in Bad Faith” who’s goal is to discredit the citizen detained for personal gain? The police will certainly pass along that information to medical staff, sometimes there is nothing in writing from police to medical staff, only a verbal subjective report. [We have been advocating for all police in Canada to provide written objective reports, but that’s not our focus on this post.] So again, how could the detainee (proposed patient) even begin to defend themselves against unlawful arrest and drugging if they are refused their requested call to lawyer under Sec. 10 of the Charter before being drugged and committed?

Both scenarios are based on real stories from Canada. From Newfoundland to Victoria, BC. There are many notable stories, I will not mention names or cities here, but the main concern/reason for my post here is this;
What protection(s)/safeguards are in place for any citizen who gets unlawfully detained by police and or medical staff under any provincial Mental Health Act in Canada? Answer: It should be Section 10 of Canada’s Charter of Rights and Freedoms Act. It does not matter if a detainee has been brought under emergency section of a Mental Health Act or not, every citizen in Canada has a legal Right to protect themselves from unlawful arrest, this includes mental health.

While studying/researching Canadian mental health law at Western, I stumbled across an important section in the following book;

‘Canadian Health Facilities Law Guide’ @ 1984, CCH Canadian Limited, Section 11, 120 pages; (pages 6040-6041) ‘Forcible Administration of Treatment’
“A difficulty yet to be addressed in Canadian case law is the issue of forcible administration of psychoactive medication. Even with precise provincial law permitting forcible use of medicine and other types of treatment it must be remembered that the Canadian Charter of Rights and Freedoms may nullify such legislation. This could be accomplished if a patient who refuses treatment files a lawsuit under the Charter. Without case law on the matter, however, the impact of the Charter on the right to refuse pharmacological treatment is now the subject of speculation. Nevertheless, the role of the Charter of Rights and Freedoms cannot be underestimated.
No mental health administrator or practitioner wants to see court action on the right to refuse treatment. Once a case is filed, it generates considerable media attention that can project a highly negative picture to the community. To avoid such difficulty, be it with compelling medication or any other form of treatment, the requirements for consent must be followed closely. In addition, health facilities and professionals must establish guidelines for handling patients who refuse treatment.”

Do we just start drugging people the second they refuse to see a medical professional? Is asking for their Canadian Charter of Rights and Freedoms Section 10 call to a lawyer a sign of mental illness? The police take a citizen to medial staff under a MHA, when the citizen is locked in a room and can in no way harm themselves or others, then why the urgent need to force them out of their clothes and medicate them. How would you react to being ordered out of your clothes and forced to accept medications against your will. Criminals have a legal Right to defend themselves, and if found guilty they do their time and can receive a Pardon from the Federal government, if found NOT GUILTY they are set FREE. BUT a citizen who has been unlawfully detained and treated under a Canadian provincial Mental Health Act will have a permanent mental health history on police file, which will follow them and their family around the rest of their lives.

Nobody but nobody could ever begin to understand what it feels like to lose their liberties, until they are forced out of their clothes and medicated and held against their free will. The police and medical professionals who deal with mental health detentions need to ensure that the citizens of their community have complete confidence in them, without that, citizens will become silent about one of the biggest things that matter, and that is ‘Mental Health’.

PROBLEM #1 – more often than not, the people brought in by the police and dropped off will at some point change their minds about “wanting” to be there.. they are often under the influence of drugs and or alcohol and extremely combative..

problem 2# police are often handing off these patients to minimum wage security guards with minimal training and authority.. it presents a dangerous situation where high turn over results in low level of experience, coupled with poor training it is only a matter of time before something serious and or horrible goes wrong..

problem 3# while I agree that pushing these patients through quickly Is practical and reasonable, the real reason this is even an issue is $$$$$$$… why pay a police officer in some cases 40-50$ an hour to sit and stair at the wall when you can pay a security guard minimum wage.. which coincidentally is usually the LOWEST paying job in the hospital and includes the highest RISK of violence or contamination. you wanna talk about cases of violence against nurses?? nobody talks about the hospital security staff… which is often hired out to a private company which is paid for example 22$ an hour, PER guard that they have on site.. whilst only paying said guards 11$.. so in actuality you create a HUGE divide between actual hospital staff and security staff.. coupled with the low budget inept level training received, what you get in a mixed security service consisting of approx. 50% idiots and 50% people who really want to do a good job…

IN HOUSE security should be MANDATED for hospitals. private security provides minimal security with an appearance of actual security..

would you let a drunk hiv positive police drop off throw feces at you for minimum wage?? didn’t think so

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.